Provider Demographics
NPI:1083196380
Name:GOLDEN, HANNAH (MOTR/L)
Entity Type:Individual
Prefix:
First Name:HANNAH
Middle Name:
Last Name:GOLDEN
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:HANNAH
Other - Middle Name:
Other - Last Name:TULL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1541 S 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-6838
Mailing Address - Country:US
Mailing Address - Phone:208-863-8733
Mailing Address - Fax:
Practice Address - Street 1:1460 ELK CREEK
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-535-1286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-1922225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist